Q&A: The Next Stage of Managed Care

Bush's health adviser on where insurance is headed

Mark McClellan, a member of President Bush's Council of Economic Advisers, brings an unusual perspective to health-care issues. An economist and a physician, McClellan has done path-breaking research into the costs and benefits of new medical technologies. Today, he is working to encourage a more efficient health-care market. BusinessWeek's Howard Gleckman asked McClellan to assess changes in private health insurance.

Q: Where do you see private health insurance going?

A: We have not quite seen what the next round of efficient health-care delivery is, but we've got a sense of some of the directions. People are looking to keep costs under control and spend dollars wisely. That's where the interesting defined-contribution plans come in.

The big trend is away from HMOs that depend very [little] on out-of-pocket payments from individuals and toward plans that rely on them more. They have people being more of a partner in their health-care purchase decisions, to the tune of 20% or 30% co-payments or substantial deductibles. But many employees are choosing that because it gives them more control over care.

Q: That requires access to lots of information. Is that information available now?

A: It's getting there. But we need to provide better information to patients about how they can get good health care. In my practice, for example, it was useful to have guidance about hospitals that tended to be better for certain kinds of care.

Q: Is there a government role in providing objective information?

A: Government can provide standards. If we've got standardized information and careful ways of making use of it, it is possible to develop better data on what works. But a lot of the innovation is coming from the private sector. General Motors has done a lot. The Pacific Business Group on Health has [done] quality measures on its health plans.

Q: Will more choice result in lower prices?

A: I think so. Patients really want to know the most effective way to treat health problems at the lowest cost.

Q: Will HMOs suffer if healthier patients shift to defined-contribution plans and other new models?

A: It's something we want to keep an eye on. Some of these plans set up features that are attractive both to people who are sick and to those who are relatively healthy. Some will give you significant catastrophic coverage [and] opportunities to see the doctor you want. But for people who are relatively healthy, they give a good package of preventive care.

Q: Americans still equate more care with better care. Can that cycle be broken?

A: This goes to the need for patients to be well informed and have the opportunity to figure out what treatment works best for them. Very often, more treatment is better. But often, watchful waiting or supportive care is a perfectly good alternative. We need to get away from one-size-fits-all and to more patient-doctor control, more patient-centered care, and more opportunities for patients to make informed decisions.

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